Registration Form for "Formulating with Lipids" Web-Based Short Course

CD-ROM ORDER FORM
Formulating with Lipids

Please print, complete, and mail this form to address shown below:

Name:

If you are an AAPS Member, please enter member number:

Organization:

Address:

City-State-Zip:

Daytime phone:

FAX number:

E-mail address (print very clearly):

Purchase Fees:

Product:	Members:	Nonmembers:
CD-ROM: Formulating with Lipids	$250	$375
4 1/2% Sales Tax for Virginia Residents Only	$11.25	$16.88

Total amount submitted: ________

Payment by check:

[ ] Check (Check Number _____________ Payable to AAPS in U.S. dollars, drawn on a U.S. bank.

Please charge my:

[ ] Visa

[ ] Mastercard

[ ] American Express

[ ] Discover

Card Number:	Expiration Date:
Cardholder Name (Print)	Auth. Signature:

Please FAX or mail the completed registration form to:

AAPS Meetings and Expositions Dept.
Attn: Andrew M Cohn
FAX = (703) 243-9650
2107 Wilson Blvd, Suite 700, Arlington, VA 22201-3946